Access to a doctor depends on how much you earn, study suggests

Dr. Stephen Hwang, from the Centre for Research on Inner City Health at the Li Ka Shing Knowledge Institute at St. Michael’s Hospital in TorontoPhoto by
St. Michael's Hospital

Some doctors’ offices are cherry-picking wealthier patients, with higher income earners 50-per-cent more likely than welfare recipients to be taken on as new patients, new Canadian research suggests.

And nearly 10 per cent of doctors’ offices surveyed were conducting “screening visits” — essentially auditioning patients to see which ones they would be willing to accept into their practices, a direct violation of their own licensing body’s policy on accepting new patients.

Appearing in this week’s edition of the Canadian Medical Association Journal, the study “provides evidence of discrimination by physicians’ offices on the basis of socioeconomic status,” the authors write.

“In my personal experience as a physician caring for people who are marginalized, I’ve been struck by the fact that many of them say they feel that they’ve been treated poorly by health care providers in the past, and that it’s in large part because they’re either poor or homeless,” said senior author Dr. Stephen Hwang, from the Centre for Research on Inner City Health at the Li Ka Shing Knowledge Institute at St. Michael’s Hospital, and the University of Toronto.

For the study, two researchers, one male, one female, telephoned 375 randomly selected family physician and general practitioner offices in Toronto between March 2011 and July 2011, posing either as an employee of a major bank who had just been transferred to the city, or as a welfare recipient.

In one script, the researchers were trained to say: “I’m calling ’cause my welfare worker told me that I need a family doctor for annual check-ups.”

The callers also mentioned whether they did or did not have chronic health conditions (diabetes and back pain).

The research team tested to see how many times the callers – fake patients – were offered an “unconditional offer” of an appointment as a new patient. Most of the responses were from secretaries or administrative assistants.

Overall, 18 per cent of requests resulted in an appointment being offered, 8.8 per cent resulted in an offer for a “screening” visit and three per cent resulted in an offer to be placed on a waiting list.

Callers posing as bank employees were significantly more likely than callers posing as welfare recipients to be offered an appointment (23 per cent versus 14 per cent), or to be offered an appointment, screening visit or a place on a waiting list (37 per cent versus 24 per cent).

The College of Physicians and Surgeon of Ontario’s policy on accepting new patients states that MDs who are able to take new patients should do so on a “first-come, first-served” basis. It also states that it is inappropriate for doctors to screen potential patients “because it can compromise public trust in the profession, especially at a time when access to care is a concern.” Screening, the college adds, “may also result in discriminatory actions against potential patients.”

“The tendency to favour people of higher status in society is probably universal. It’s something I’m conscious of in myself — I have to guard against that tendency,” said Hwang, a specialist in general internal medicine who cares for patients in hospital, as well as the homeless in the community.

“It may actually be unconscious bias rather than a conscious prejudice.”

In a written statement, the doctors’ college said that, in developing it policy, “the college’s council felt strongly that when physicians are able to accept new primary-care patients, the first-come, first-served approach is the easiest and fairest way to do so.”

Patients are encouraged to contact the college if they feel a physician has discriminated against them, the college said, adding that “we take these complaints seriously.”

To Hwang’s surprise, people with chronic health conditions were more likely to receive an appointment than those without (24 per cent versus 13 per cent). The researchers had expected healthy people would be given preference because they take less time and work.

Under fee-for-service payment schemes, there may be a financial incentive to accept patients with chronic health conditions.

However, the opposite would be true under “capitation,” where doctors are paid a fixed amount per year per patient, whether they see the person once a year, or 20 times a year.

Overall, people with high socioeconomic status and chronic health conditions had the best shot — 29 per cent — of getting an appointment.

Hwang cautioned that, in almost every case, the researchers were speaking to office staff, and not to the physicians themselves.

“One possible explanation is that some of the office staff who answered the phone may have an unconscious bias against people who are of low income, and particularly people on welfare,” Hwang said.

But it’s also possible that the doctors for whom they work “have instructed them to select certain kinds of patients to be selected into the practice,” Hwang said.

Either way “if you can’t get past the office staff to get an appointment, then you won’t see the physician.”

The study involved only a small proportion of the nearly 3,400 family doctors and GPs practising in Toronto. “It’s not evidence that most offices discriminate,” Hwang said. But it suggests that some do, he said.

Although the study was conducted in Ontario, Hwang said he has no reason to believe the findings would be different in any other province, especially where doctors’ shortages exist, “and there are more patients looking for physicians than there are physicians providing care.”

In Canada, 15 per cent of Canadians report that they don’t have a regular family doctor.

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